Provider Demographics
NPI:1104859461
Name:REID, BRUCE EDWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EDWIN
Last Name:REID
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:400 ERNEST W BARRETT PKWY NW
Mailing Address - Street 2:SUITE 297
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4917
Mailing Address - Country:US
Mailing Address - Phone:770-421-1734
Mailing Address - Fax:
Practice Address - Street 1:400 ERNEST W BARRETT PKWY NW
Practice Address - Street 2:SUITE 297
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4917
Practice Address - Country:US
Practice Address - Phone:770-421-1734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1114T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist